Published in the United States of America by
IGI Global
Medical Information Science Reference (an imprint of IGI Global)
701 E. Chocolate Avenue
Hershey PA, USA 17033
Tel: 717-533-8845
Fax: 717-533-8661
E-mail: cust@igi-global.com
Web site: http://www.igi-global.com
Copyright © 2020 by IGI Global. All rights reserved. No part of this publication may be
reproduced, stored or distributed in any form or by any means, electronic or mechanical, including
photocopying, without written permission from the publisher.
Product or company names used in this set are for identification purposes only. Inclusion of the
names of the products or companies does not indicate a claim of ownership by IGI Global of the
trademark or registered trademark.
			

Library of Congress Cataloging-in-Publication Data

Names: Stefaniak, Jill E., 1984- editor.
Title: Cases on instructional design and performance outcomes in medical
education / Jill Stefaniak, editor.
Description: Hershey, PA : Medical Information Science Reference, 2020. |
Includes bibliographical references and index. | Summary: “This book
examines the design and delivery of education programs for healthcare
professionals and provides them with the foundational knowledge needed
to design effective instruction for a variety of audiences and learning
contexts”-- Provided by publisher.
Identifiers: LCCN 2020000781 (print) | LCCN 2020000782 (ebook) | ISBN
9781799850922 (hardcover) | ISBN 9781799850939 (ebook)
Subjects: LCSH: Medical education--Study and teaching--Case studies.
Classification: LCC R834 .C37 2020 (print) | LCC R834 (ebook) | DDC
610.71/1--dc23
LC record available at https://lccn.loc.gov/2020000781
LC ebook record available at https://lccn.loc.gov/2020000782
This book is published in the IGI Global book series Advances in Medical Education, Research,
and Ethics (AMERE) (ISSN: 2475-6601; eISSN: 2475-661X)
British Cataloguing in Publication Data
A Cataloguing in Publication record for this book is available from the British Library.
All work contributed to this book is new, previously-unpublished material.
The views expressed in this book are those of the authors, but not necessarily of the publisher.
For electronic access to this publication, please contact: eresources@igi-global.com.

Cases on Instructional
Design and Performance
Outcomes in Medical
Education
Jill Stefaniak
University of Georgia, USA

A volume in the Advances in
Medical Education, Research, and
Ethics (AMERE) Book Series

92

Chapter 5

Virtual Reality Stereoscopic
180-Degree Video-Based
Immersive Environments:
Applications for Training Surgeons
and Other Medical Professionals

Maxime Ros
https://orcid.org/0000-0002-2149-165X
Revinax®, France & Educational Sciences Department, University of
Montpellier, France
Lorraine Weaver
Thompson Rivers University, Canada
Lorenz S. Neuwirth
https://orcid.org/0000-0002-8194-522X
Neuroscience Research Institute, SUNY Old Westbury, USA

EXECUTIVE SUMMARY
The theoretical and practical applications of immersive VR, although relatively new,
have accomplished much in the area of pedagogical learner applications. This chapter
describes the conceptual framework and Revinax® 180-degree stereoscopic videobased approach in addressing the academic achievement gap through conventional
surgical students and nurses shadowing and how immersive VR environments may
best address leveraging the learner’s capability of increasing their skill acquisition,
learning, and knowledge retention in a more efficient time-period, circumventing the
inherent issues with conventional shadowing. Further, these VR experiences through
DOI: 10.4018/978-1-7998-5092-2.ch005
Copyright © 2020, IGI Global. Copying or distributing in print or electronic forms without written permission of IGI Global is prohibited.

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

first-person Point of View (POV), although simulated and artificial, evoke mirror
neurons, and can recruit neurocircuitry that are imperative for skill acquisition
and later skill application. As such, the Revinax® instructional design model may
provide a unique insight in how to use immersive VR environments to teach any
learner that seeks to acquire surgical/medical professional training more efficiently
and practically in a modern world of technology.

INTRODUCTION
New technological programs, tools, and devices often create excitement and curiosity
as people seek to learn about new technologies and their potential future applications.
This is especially true for individuals that given their specific job/training roles, could
find ways in which technology can help them complete their work more effectively
and efficiently. Thus, it is not surprising that many educators and future generation
learners are currently increasingly exposed to pedagogical approaches targeted at
technology-dependent learning instruction over conventional approaches. Such
modern pedagogical technology-dependent approaches have already begun, yet as
many emerge, a clearer understanding of their utility, generalization, and translational
application(s) from the learning environment into real-world contexts, become the
greatest sought after outcome measure. Further, some of these technology-dependent
applications may be less educationally immersive (e.g., avatar simulations, 2-D
video simulations, passive video recording instruction, etc.), while others can be
more educationally immersive (e.g., virtual reality [VR], stereoscopic first-person
point-of-view [POV] instruction, etc.). Therefore, during such a technologically
expansive, exciting, and necessary time-period, educators are seeking novel and
effective approaches for elucidating which technological programs, tools, and devices
would be best suited for their pedagogy is warranted. In order to shed light on this
very issue, the present study offers an unbiased assessment of how VR can be used
in novel evidence-based ways for assessing educational training of surgeons and
other medical professionals.
As such, VR has evolved significantly from its inception in the 1950s (For
Review See Mandal, 2013) and is presently emerging as a versatile pedagogical tool
that can be used to train surgeons more effectively and efficiently across a number
of medical interventions (Alaker, Wynn & Arulampalam, 2016; Vaughn, Dubey,
Wainwright & Middleton, 2016; Aim, Lonjon, Hannouche & Nizard, 2015; Ragan
et al., 2015; Anderson, Winding & Vesterby, 2011; Gurusamy, Aggarwal, Palanivelu
& Davidson, 2008; Aggarwal et al., 2007; Haque and Srinivasan, 2006). Despite
the fact that VR encompasses a wide range of user experiences that are appropriate
93

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

for different training objectives and applications, it has also been shown to have
an increasing demand and interest in the educational training of more medical
applications (Kamińska et al., 2019; Górski, Bun, Wichniarek, Zawadzki & Hamrol,
2017;). Consistent with these current trends, Revinax® has uniquely integrated VR
technology with the use of a stereoscopic 180-degree video-based intervention to
provide surgeons and other medical professionals with a first-person POV of the
surgical procedures that they will be trained on, in addition to accessing other relevant
patient data as part of the curriculum for a surgical training program. The goal of
this surgical training program was to: 1) provide video-based evidence of the value
of stereoscopic 180-degree VR; 2) establish the importance of its technological and
curricular design; 3) discuss what the field can learn from modeling, validating,
reliably testing, and/or building upon such pedagogical technologies; and 4) how such
technology can be effectively used for educating medical students and professional
on surgical interventions through more immersive experiences.

WHAT IS VIRTUAL REALITY (VR)?
There are many definitions of VR, partly because of the wide range in which it is
executed in order to achieve the context-specific goals of the design team. Some
current examples of VR definitions are: creating digital worlds/environments suitable
for real-time human learning (Górski, Bun, Wichniarek, Zawadzki & Hamrol,
2017), an environment for users to interact with artificial stimuli in a somewhat
naturalistic way (Concannon, Esmail & Roduta-Roberts, 2019), “an artificial threedimensional environment…presented to a person in an interactive way” (Kamińska et
al., 2019, p. 2), and as an environment which promotes immersion, interactivity and
imagination (Concannon et al., 2019; Kamińska et al., 2019). These VR definitions
provide the theoretical framework from which pedagogical instructional designers
can begin to envision the kinds of artificial, somewhat naturalistic, and immersive
environments that they would like to create as part of their curriculum. Further, the
exact time-points or active learning opportunities that they envision, can then be
pre-determined within these VR environments to control and investigate through
evidence-based means, how the student users’ interactivity within and responsivity
to the VR environment can be investigated. This latter point is pivotal since the
instructional design of VR environments have varying levels of user immersion, and
without such proper instructional design intention and controls in place, identifying
an evidence-based pedagogical approach through VR would be obscure. Arguably,
the levels of user immersion within the VR environment, directly relates to whether
or not a user can experience aspects of the VR environment that will facilitate
them in obtaining a simulated sensory experience of the real-world (Concannon
94

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

et al., 2019). Moreover, the levels of immersion experienced by the user directly
affects how “actively present” the user feels within the VR experience (Górski et
al., 2017). Kamińska et al. (2019) notes that the “level” of immersion that the user
experiences should be adjusted based upon the curricular training goals with the
lowest-level of immersion being used for knowledge acquisition (i.e., the short-term
learning objective), a moderate-level for skills acquisition (i.e., sustained learning
acquisition and skills maintenance), and a high-level of immersion for problem
solving (i.e., applied learning, contextual (re)organization, and generalization of
skills learned from one environment to another). According to Fowler et al. (2015)
the most important factors that are used as criteria to obtain a successful 3D VR
learning environment/experience for the user are: 1) presence (i.e., the user feels as
if he or she were within the environment), 2) co-presence (i.e., the user feels as if
other people were within the environment), and 3) interactivity (i.e., the user feels
as if they can manipulate, explore, or become apart of the environment). Thus,
immersive VR (i.e., accompanied by a headset otherwise referred to a head mount
display [HMD]) can achieve and/or fulfill all of these factors, thereby meeting the
criteria for an effective and user optimized 3D VR learning environment/experience.
Indeed, beyond immersion-dependent learning processes, an equally important
instructional design feature of VR environments are the varying levels of interactivity
that provide opportunities for how the user and their (in)actions can relate to
how the users can manipulate the VR environment (Concannon et al., 2019).
Some examples of interactivity are input devices that can include motion-sensing
gloves, controllers or photo sensors that allow the user to see and use their hands
within the VR environment (Concannon et al., 2019; Górski et al., 2017). Some
VR environments also provide haptic (i.e., tactile vibration-dependent sensory
reception or proprioception) feedback or resistance to simulate an immersive sensory
experience (Concannon et al., 2019; Górski et al., 2017). The amount of control
that a user has within the VR environment can directly influence how “real” the
experience is perceived and whether or not the user feels “present” within the VR
environment (Concannon et al., 2019). Notably, how closely “the user’s actions,
senses and thought processes…resemble those that would be experienced while
in the same situation…in the real world” (Concannon et al., 2019, p. 4) is known
as fidelity (i.e., influence of believing the “realness” of such VR environments).
It is imperative that the physical, functional, and psychological fidelity of the VR
environments in which the users experience be examined separately to address where
the instructional design and curricular content provide the most interactivity for
the user to achieve an optimal and believable learning outcome (Concannon et al.,
2019). This would promote the user’s perception of a high fidelity VR environment
that would simulate real-world training and generalization. However, using such
VR instructional design should be cautioned as it can be extremely expensive to
95

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

recreate 100% matched simulations to real-world events, may not be practical in
some circumstances, and are not always required in order to reach the educational
learning and training goals sought after.

DECIDING WHEN VR INSTRUCTIONAL
DESIGN WOULD BE BENEFICIAL
Despite how luring VR environments might appear if they were to be used in
an educational instructional design, educators should caution themselves as VR
environments may be advantageous for some learning/training objectives, but may
equally have pedagogical limitations. Thus, it is essential to understand both the
benefits and challenges associated with using VR environments pedagogically, in
order to understand the ceiling and floor effects of VR environments within the
pedagogical context of instructional design (Fig. 1).
Despite the number of levels created within an immersive VR environment, the
instructional designer must be cognizant of the practical limits in overwhelming the
user with too many immersive aspects (i.e., ceiling effect), and ensuring to provide
just enough immersive aspects (i.e., floor effect) to optimize the user’s attention and
learning. Moreover, it is important to highlight that the immersive VR environment
helps to reduce cognitive load and if too many pedagogical approaches are given at
once, it may be counterproductive.
Figure 1. Instructional design concept map for understanding the ceiling and floor
effects of an immersive VR environment
© 2020, Ros & Neuwirth. Used with permission

96

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

By following this instructional design concept map, the outcome would be an
immersive VR environment optimized for the user’s education. This outcome could
then maximize the user’s learning benefits by reducing unnecessary distractions
(Harrington et al., 2018), and overcome the user’s learning obstacles by making the
content just surpass the most minimal arousal levels. Further, this concept map would
help overcome the inherent issues with VR environments where an instructional
designer’s vision must meet a user’s adaptation to and ongoing engagement within the
VR environment to develop an ideal pedagogical application for training/educational
programs. Notably, these user benefits and challenges may differentially influence
the instructional design and training objectives of VR environments. Górski et
al. (2017) suggested that there were three distinct, yet different, levels within the
educational medical VR environment applications: 1) general (i.e., conceptual skills),
2) procedural (i.e., behavioral/ adaptive skills), and applied knowledge (i.e., practical/
generalization skills). Figure 2 illustrates the conceptualized differences between
the user’s knowledge levels directly related to the instructional design variations
are required to reduce any potential academic achievement gaps when constructing
an effective VR environment for pedagogical applications (Górski et al., 2017).

BENEFITS OF IMMERSIVE VR ENVIRONMENTS:
ACCESSIBILITY, AUTONOMY & COST
Accessibility Within Immersive VR Environments
“Accessibility refers to the user’s ability to find what is needed, when it is needed.
Improved access to educational materials is crucial, as learning is often an unplanned
experience.” (Ruiz, Mintzer & Leipzig, 2006, p. 208). Consistent with this quote,
VR environments can allow users anywhere in the world to access the same training
so long as they have access to the required technological devices to permit them to
become immersed within the experience (Kamińska et al., 2019). Accessibility of
an effective education is perhaps best captured by the following quote: “Learning is
a deeply personal experience: we learn because we want to learn.” (Ruiz, Mintzer
& Leipzig, 2006, p. 208). However, knowing the needs of the prepared and/or
underprepared user is a critical factor in which their autonomy within an immersive
VR environment may help to facilitate their learning and produce better educational
outcomes, irrespective of the academic achievement gap.

97

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

Figure 2. Illustrates the conceptualized instructional design for the developing VR
environments for ensuring optimal educational outcomes for the user based on the
models proposed by Górski et al. (2017)

(A) displays the venn diagram of the Górski et al. (2017) model when the VR user’s experience is
balanced in learning content across conceptual, behavioral/adaptive, and practical/generalization skills
(B). Further, instructional designers should be aware to permit flexibility for the user to adapt within
such VR educational environments whereby at time they may need more conceptual than practical
skills (C), more practical than conceptual skills (D), more behavioral than conceptual skills (E), and
more behavioral than practical skills (F). Permitting such flexibility may create more immersive VR
environments with greater educational gains for the user.
© 2020, Ros & Neuwirth. Used with permission.

Autonomy Within Immersive VR Environments
Beyond accessibility, VR environments differ in the degree of autonomy that
individual users might experience when accessing the identical VR environments
repeatedly over time. Some VR environments can be accessed and experienced by
the user, while others require an instructor to set them up or run the experience for
a single or group of prospective users (i.e., shared VR experience), and lastly, some
are designed to require other users to interact with the main user (i.e., cooperative VR
experience) within the VR environment to complete a single experience (Kamińska
et al., 2019). Therefore, the degree of the user autonomy is directly influenced by
the desired educational goals of the training and the instructional design of the VR
environment, in turn, defining the user’s VR overall experience. However, identifying
98

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

how much user autonomy is needed for the instructional design is a critical factor
in determining the cost of developing immersive VR environments for pedagogical
purposes.

Cost of Developing Immersive VR Environments
Monetary savings can be achieved over time when comparing the use of VR with 3D,
2D, and real models, as well as, tissues or patients (Górski et al., 2017). However,
in the initial development stages of any technological tool, device, or software
costs can be exorbitant. Because of these financial challenges in developing VR
environments, a balance must be achieved between leveraging the expenses that
go into developing the VR instructional curriculum and design, while maximizing
the pedagogical/educational outcomes and detailing such cost comparisons for
future research and development of VR experiences (Fig. 3). Such information
can help future educational instructional designers of high-quality high-return
investments compared to low-quality low-return investments when developing
new VR environments for applied pedagogical instruction. Further, knowing such
information may be essential in motivating and capturing the interest of users to
seek engagement in VR environments within an educational context.
Figure 3. Probability squares of assessing cost and returns for developing effective
applied learning technologies in VR Environments for conceptual (A), behavioral
(B), and practical (C) instructional design
© 2020, Ros & Neuwirth. Used with permission

The ideal situation is to maximize high returns from the lowest cost across
each of these three factors, but often times that may be less than ideal.Novel VR
enviornments might require high cost to initially develop high returns and over time
can be economically reassessed.

99

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

It is also imperative to understand how such a pedagogical immersive VR
environment can transcend a wide-range of conceptual parameters to increase the
user/learner’s ability to fully comprehend what is being presented to them (Fig. 4).
Figure 4. Illustrates a conceptual framework for designing the most optimal immersive
VR environment across a number of factors (i.e., conceptual – CGI, practical – CGI,
practical 180-degree vide-based, and behavioral 360-degree video based) as they
would relate to low and high returns (i.e., the financial investments that go into
creating the technological and the pedagogical gains achieved by the user/learner).
© 2020, Ros & Neuwirth. Used with permission

Obtaining and Sustaining User Motivation and
Interest Within Immersive VR Environments
The use of exploring VR environments in grade school curriculums (i.e., “VR
field trips” in middle school students’ social studies) has been shown to increase
educational motivation and interest (Kamińska et al., 2019). Further, studies focusing
on the use of VR technology in different learning contexts supports the findings that
learners are more engaged and self-report that they understand the content being
taught better. These benefits may come from the lower “task-unrelated images or
thoughts” (Harrington et al., 2018, p. 993) (i.e., improved attention) that are brought
out through the immersive characteristic of these VR experiences. These findings
are further supported by data showing that blinding students to the actual VR
environments that they will be immersed into actually increases their focus upon
entering the VR-environment. Harrington (2018) showed a significantly higher student
level of engagement (i.e., 360 video-based instructional content) and the student’s
100

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

preferred it when compared to a 2D video of the same content. This might be a key
factor that warrants further investigation in developing VR immersive environments
that encapsulate meaningful engagement for the learner through depth perceptual
processing and/or visual feedback, which is critical for transferable pedagogical
outcomes in VR environments. Ultimately, this type of learning could positively
influence student’s preference for a VR curricular format over others that in turn,
promotes an increase in student motivation and educational interest.
Ekstrand (2018) stated that VR prevented “neurophobia” (i.e., a fear of learning
neuroanatomy), which provided insight in expanding the pedagogical approach
from just viewing content to include exposure and re-exposure of the same content
to increase user acceptability of the information being presented/taught. Using
Computer-Generated Imagery (CGI) to reconstruct the neuroanatomy among 175
students, of which, 94% were willing to have VR integrated in their educational
curricula because it helped them to improve their understanding of the course content.
Thus, students directly report that having a better understanding of educational
content can be achieved through VR, and then having the luxury of going over it
multiple times, can facilitate a self-regulated means of adapting to and desensitizing
students to their own inherent fear(s) of learning neuroanatomy. This latter point is
compelling as it provides invaluable insight into the utility of VR when the user can
determine how frequent they would like to experience the course content. This could
further provide the instructional designers to anticipate the learners with the ability
to augment and adapt within the VR environments to increase their motivational and
educational interests in response to uninteresting, aversive, or noxious educational
content. Such insightfulness can help the instructional designers to create supportive
VR environments that may best address their academic achievement gaps with course
content that intimidates them such as neuroanatomy and other forms of biological
dissection of tissues (i.e., both human and non-human).
Further, “neurophobia” has been an emerging issue that can also deter students
from entering the biological and medical science fields and may reduce future
medical professionals in the science, technology, engineering, and mathematics
(STEM) fields if left unaddressed (For Review See Neuwirth, Dacius, & Mukherji,
2018); yet, VR might be able to leverage this very issue in a responsible and ethical
manner through creative instructional design of VR environments that combine
exposure/re-exposure immersion levels that desensitize the user to content that they
might find aversive. By providing the user with the control to regulate how much
they would like to tolerate in becoming immersed in such VR content, this may
actually decrease their mental workload and increase learning. Further, if the user
can control the VR environment this may increase engagement from students who
would otherwise view the material as aversive and mostly result in course attrition,

101

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

to follow through with the curriculum and perhaps continue to learn more content
beyond the VR module.

Reduced Mental Workload Through
Immersive VR Environments
Notably, VR can increase the user’s motivation and interest, which makes it an attractive
technology for integrating educational content with an immersive experience that is
uniquely memorable. However, as with any attentional task, one’s attention span and
cognitive load can either be limited or limit how much information one attends to at
a given moment in time (Feldon, 2007; Barrouillet, Bernardin, Portrat, Vergauwe
& Camos, 2007; Oviatt, 2006). Unlike standard visual and attentional processing
where humans are easily distracted by events, actions, objects, and movements within
their visual field, VR headsets block out these competing peripheral and background
distractors and increase the user to focus their attention on the foreground of the VR
environment. The attention to the VR environment is also enhanced due to its novelty
(Roussou, 2000). Thus, it can be argued that through these inherent features of VR,
it may reduce the user’s attentional load and free up more cognitive capacity stores
for increasing skill acquisition and learning retention (Andersen, Mikkelsen, Konge,
Cayé-Thomasen & Sørensen, 2016) to be freely available to become increasingly or
fully immersed within the VR experience; thereby, facilitating the user’s learning,
memory, and post-educational outcomes.
Moreover, since VR also facilitates the first-person POV, this particular feature
has also been suggested to further reduce the user’s cognitive load to increase their
learning capacity just by using the first-person POV. The first-person POV has been
shown to improve the learning of new gestures. Mirror neurons are usually activated
when the learner sees someone else performing a procedure. If this procedure is
viewed from a first-person perspective, cognitive load is less important, and trainees
are more able to replicate the procedure. (Fiorella, Van Gog, Hoogerheide & Mayer,
2017).
This latter point is critical as mirror neurons are the neurobiological/
neuropsychological basis for empathy (Iacoboni, 2009), vicarious reinforcement,
(Bandura, Ross & Ross, 1963), and more relevant to this VR context and enriched
sense of learning that is validated by the user’s brain responsivity to VR and their
brain’s ability to perceive the POV as being the user’s own first-person experience.
Thus, the first-person POV constitutes a powerful way in which 3D 180-degree
stereoscopic VR experiences directly influencing the user’s brain in ways that can
optimize learning through VR environments that provide sound evidence that it
can offer unique pedagogical benefits to the learner/user by improving their skill
acquisition and memory retention.
102

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

Improved Learning Skill/Performance Acquisition and
Memory Retention Through Immersive VR Environments
Several studies have begun to address the issues of learning performance and
retention when using VR environments. In order to address this issue, the pedagogical
designer’s instructional plan must be comprised of a step-by-step approach that
directly scaffolds the short-term learning objectives with the desired long-term
learning outcomes of the curriculum. However, despite even the most well-defined
and structured curriculum in VR, some difficulties might arise from the wide
variety of and different intentions for how the VR environment was implemented
within a given curriculum. Together, this begets the questions, which VR studies
are consistent, reliable, and comparable in best addressing the issue of standardizing
key factors for using VR in best pedagogical practices for educating the next
generation learners. It may very well depend on the type of VR that is studied (e.g.,
CGI, 360-degree video, 180-degree video, etc.), since the pedagogical objectives
(i.e., theoretical, procedural, practical knowledge, etc.) and what they are compared
against (e.g., books, videos, lecture, physical simulator, etc.) may be more important
in capturing the user/learner’s attention and sustaining their cognitive loads, while
diminishing distractors to improve learning outcomes. Further, it has been shown
that non-immersive VR can lead to improved educational performance (i.e., less
errors and reduced time to complete the task) in reproducing complex tasks, when
compared to technical manuals and multi-media films. For simple tasks, there
were no differences observed between non-immersive VR and multi-media films
regarding the number of errors, but non-immersive VR did speed-up the time to
complete tasks (Chao et al., 2017).
Another study by Smith (2018) aimed to compare computerized-images displayed
between immersive VR, flat-screen VR, and written notes after having watched a
video. They assessed the performance on a mannequin and measured their time to
completion. The results showed that they failed to observe any short-term or midterm (i.e., 6 months follow up) differences between the groups, when compared to
immersive VR. Surprisingly at mid-term, the non-immersive solutions produced
significantly faster time to task completion when compared to baseline, but again
without any significant difference between groups. Sheik-Ali (2019) mentioned that
the speed to meet criteria is an important variable, but more importantly, in a surgical
training context, the speed of surgical skill acquisition is arguably more important in
order to become proficient enough to complete a later surgical task. They concluded
that many studies have consistently shown a positive linear relationship between
the use of VR/AR in surgical training and surgical skill acquisition, despite the
tools used being rather different. To be clear, there is only one immersive VR tool,
which uses hand-tracking instead of remotes. Regarding the influence of immersive
103

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

VR with CGI to complete a task, Smith et al. (2018) found no difference between
the group using immersive VR and the group receiving conventional training.
The authors further showed the same post-interventional outcomes with gradual
improvements and lower retention scores at 6-months follow up. Thus, they stated
that VR was at least as good as conventional training but did not surpass it. In a
recent study, Andersen et al. (2018) showed that using VR with CGI for practical
knowledge before a training course increased the benefits of the course and allowed
the students to achieve better learning outcomes. They also showed that the more
people were trained repeatedly in VR, the better their results were when compared
to a single training of VR. This suggested that VR has additional educational gains
influencing skills acquisition and memory retention through repeated exposures.
Regarding the theoretical knowledge and skill acquisition in healthcare, usercases are similar to industrials cases: the possibility to enter a 3D reconstruction of
a “machine” provides a better conceptual understanding. The possibility offered
by VR to uniquely explore the educational content through an “anatomy journey”
(i.e., through VR moving through a biological organ to view new perspectives and
connections within and across systems). Using a 3D CGI reconstruction of an organ,
which is literally put in front of the learner to let the user artificially enter through
and rotate this organ with intent that the user will become more familiar with the
course content regarding knowledge of the organ. This way the user can explore
the organ under every angle and have a better understanding of the different tissue
layers and the relations between organs. Further, this experience offers the learner
the ability to adopt a new perspective, that could not otherwise be achieved, without
the VR environment. This finding is not only fascinating, but offers an endless range
of new pedagogical possibilities. Therefore, VR is not only an entertaining way to
learn new skills through technology, but it actually improves the learners “visual
field” (i.e., a VR-induced Proprioception) thereby expanding their understanding
and approach to finding additional solutions to conventional learning problems. The
exposure to these unique perceptual angles and vantage points is perhaps the largest
advantage of using immersive VR environments over other forms of technology and
conventional educational learning. Since these VR environments are based upon
CGI that is directed by the theoretical knowledge underlying the course content,
which are then aimed at increasing skill acquisition and retention of the content to
be learned by the user. Concerning neuroanatomy, Ekstrand et al. (2018) found no
difference in effectiveness between VR and textbooks as learning tools. However,
they showed that VR prevented “neurophobia” among 175 students, and the authors
stated that the results were encouraging. This may be perhaps due to the user being
able to alter the imagery in the VR environment when compared to the fixed imagery
presented by the textbook.

104

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

In cardiac anatomy, Maresky et al. (2018) found improvements in the user’s
results after learning through immersive VR environments. Thus, VR helps students
to gain a better understanding of the organ itself, its structure-function relationships,
its spatial connections, and its interfaces within systems biology, that can create a
greater comprehensive understanding of the material within minutes in an immersive
VR environment that would otherwise require reading hundreds of pages and weeks
to months to achieve such understanding through conventional means. Another
important feature is that VR environments in the biomedical fields help to overcome
a real educational resource issue. Most dissections and surgical techniques are done
in a time restricted and sample/organ tissue availability-dependent course (i.e., the
dissection or surgical laboratory). These laboratory courses require many students to
shadow the instruction with little to no hands-on experience and often times result in
less than optimal time viewing the actual procedure or details of the procedure that
reduce the skills acquisition and applied learning of these concepts. Through VR
environments, these learning gaps can be reconciled, improved, and even enhanced
to prevent such learning gaps from occurring. These finding beg the question,
how can immersive VR environment improve the user’s learning retention? It is
hypothesized that because immersive VR environments probably facilitate the user
to understand better theoretical questions by being able to manipulate the structures/
organs and understand how it works in a constructivist approach, or to acquire
practical knowledge by being able to literally “live in an educational experience”
and its different steps. Becoming fully aware, the user/learner has all what they
need to gain a better understanding of the course content, which may then foster
better skills acquisition and memory retention for generalization of applied learning.
Altogether, the immersive VR environment may optimize the benefits of a lesson
beyond convention pedagogical approaches, but would require standardization in
order to accomplish this task.

Standardization of Immersive VR Environments
Similar to e-learning Ruiz et al. (2006) showed that the use of immersive VR
environments standardizes the educational content and provides the same information
and learning experience to all students, when compared to conventional learning.
Further, the experience that is created in the immersive VR environment by the
instructional designer and experienced by the user are equivalent to the teacher
designing the curriculum and the student learning from the conventional educational
experience. However, when an immersive VR environment is used for pedagogical
purposes, this standardization may begin to exceed the expectations and expand the
potential limits for the user/leaner; albeit, still within a standardized curriculum/
environment.
105

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

Safety of Immersive VR Environments
The immersive VR environment often allows the user to acquire the necessary
training to do things that would otherwise be too dangerous (i.e., an animal dissection,
dissecting a brain, or human organ, calculating a drug dosage to give a patient, etc.)
for most people to experience as a first time exposure within a real life situation
(Concannon et al., 2019). Thus, such use of immersive VR environments can improve
both the safety of the user/trainee/student as well as the individuals they might have
to help post-training in real situations that are dangerous. Using a similar logic with
respect to surgical education, the use of immersive VR environments can allow the
user to acquire technical skills in a simulated environment without the possibility
of harming patients (Concannon et al., 2019). This enhances the ethical component
of the pedagogical approaches through immersive VR environments and further
can increase the user/trainee’s skills, confidence and decrease surgical risks that
might otherwise occur in patients. Alternatively, immersive VR environments can
be used for a situation that one specialist must know, and further through repetitious
learning/exposure/re-exposure, it can help the younger students/professionals to be
ready faster, which was one of the first immersive VR tutorials created by Revinax®
(Ros et al., 2017). Moreover, immersive VR environments can help the user to
face/experience situations that are rare, while increasing the user’s readiness for
real-life situations based upon their VR training. For example, Vankipuram (2014)
developed an immersive VR simulator for resuscitation illustrating the utility of VR
in this very generalizable translation of knowledge across VR to real-world contexts/
environments. Figure 5 below summarizes the overall instructional design goals
for creative optimal immersive VR environments, in which the Revinax © model
endorses and applies to their pedagogical framework for creating educational VR
experiences with content that is learned faster, remembered more, and promotes
skill acquisition and generalization from VR to real-world applications.
The goal is to balance the user’s accessibility, cost, motivation and interest,
amongst safety and standardization. The adaptive ability of the immersive VR
environment should address decreasing the user’s mental workload and increasing
their performance and retention as a validity and reliability measure for successful
pedagogical applications.

CONSIDERING SELF-REPORTED ADVERSE EFFECTS OF VR
Nausea and dizziness (i.e., called VR sickness, motion sickness, simulator sickness
and/or cyber sickness) can also occur for a temporary time-period when participants
are immersed in the VR environment (Concannon et al., 2019; Kamińska et al.,
106

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

Figure 5. illustrates the conceptual model for developing an optimal immersive VR
environment
© 2020, Ros & Neuwirth. Used with permission.

2019). This occurs when participant’s movement within the VR environment does
not match their movement in the physical world (i.e., a perceptual kinesthetic
mismatch). Besides people who suffer from internal ear dysfunction, several factors
can potentially contribute to experiencing sensations in VR that may result in this
feeling. Consequently, the hardware used (i.e., VR headset), the resolution quality of
the VR displayed, and the refresh rate of the video frames captures, are among the
main contributing factors for VR sickness. Alternatively, the quality of the content:
frames per second, resolution, and movements can also contribute to VR sickness.
Notably, VR sickness happens infrequently, but can occur in people who do not
suffer from motion sickness, but is brought on by the novelty of the first time they
are exposed to VR combined with feelings of nervousness due to the uncertainty
of this new experience.

107

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

REVINAX® STEREOSCOPIC 180-DEGREE ENVIRONMENT
A Peculiar Instructional Design
The immersive VR environment that is typically created is often based upon either
CGI or 360-degree video-based experiences. Additionally, CGI helps to recreate
an environment and make an artificial environment seem more realistic to the user,
whereas in contrast, 360-degree video-based experiences simply display real footage.
Thus, CGI is interesting as it offers a unique platform in which to represent things
that cannot be recorded and played back. Since CGI attracts much interest due to
its full user interaction within the immersive VR environment, as a by-product, its
pedagogical value becomes increasingly important. However, the main problem in
developing immersive VR environments with such pedagogical value is that the cost
to create this content is rather expensive (i.e., additional design features and the more
realistic the desired experience the more it will be expensive). Moreover, the time to
create and deploy this high-value pedagogical immersive VR environment will still
require hardware for it to be used in a dedicated/restricted area (i.e., which are not
totally standalone). The 360-degree video-based experiences can supplement the
immersive VR environment by helping people to project/insert themselves within the
VR content, context, and/or situation that is pedagogically designed by the instructor.
The user interaction comes from the unique experience (i.e., perceived simulation
of a first-person POV) and what is then captured by embedded questions or decision
trees testing the users/learners comprehension of the task within the immersive
VR environment as it appears on the movie through these 360-degree video-based
displays. These videos are faster to produce than CGI, the content is intrinsically
realistic (i.e., as they are pre-recorded from real-life events) and it is therefore easier
to deploy even outside of the traditional VR HMD. However, the problem arises in
360-degree video-based displays when the user is trying to learn how to complete a
procedure (i.e., practical knowledge), since they are not fully capable of positioning
themselves within the first-person POV to activate their mirror neuron systems to
fully immersive themselves within the VR pedagogical content as intended. Revinax®
produced in 2014 a stereoscopic 180-degree 3D video-based recording of an actual
surgical procedure in real-time and since 2015 has been dedicated to advancing and
further developing this technology as a pedagogical tool based on user feedback.
Revinax® accomplishes this by creating a tutorial that involves three steps: 1) the
surgical procedure is recorded in 3D video-based format from the surgeon’s point
of view (i.e., using the equipment worn by the surgeon performing the procedure
in real-time); 2) the 3D movie is then organized into chapters corresponding to the
different steps of the surgery (i.e., with calibration and synchronization of the two

108

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

videos); and 3) clinical imaging and data are then incorporated into the tutorial to
make it a pedagogical immersive VR environment.
Among the content created, the surgical video covering the medical procedures for
carrying out an external ventricular drainage, was instrumental in allowing trainees/
students to view the procedure from a first-person POV perspective with the following
educational intervention-based goals: 1) enhancing their memorization, 2) increasing
their understanding of and confidence in implementing the procedure, 3) minimizing
error when conducting the procedure, and 4) ultimately the training/educational
intervention would decrease both surgery risks and time in surgery. Trainees/students
could also access other patient data that underwent the same procedure to help them
draw comparative assessments, weigh out any other alternative risks and/or concerns
that they might have in replicating the procedure, and increasing their reliability of
the procedure to better understand the case study with deeper analytical, critical,
and clinical thinking. Further, theses resources were supplemented in the immersive
VR environment with the patient’s Computerized Tomography (CT) scan and an
educational 3D model of the organ in which the surgery would occur. Taken together,
this immersive VR environment in theory provides in a “hands-free” manner, virtual
surgical, clinical, and educational resources that could be potentially be used in realtime within an operating room prior and during surgical interventions. However,
it is also important to note that while in the operating room, the trainee/student/
surgeon user could pause or replay the immersive VR 180-degree stereoscopic
video-based intervention and view patient data, without actually making decisions
to guide the surgery or actively influence their environment. The unique experience
that Revinax® designed was, in this particular context to allow an immersive view
of the surgery while allowing access to other patient information. The first-person
POV allows the user to see themselves as if they were the actual surgeon performing
the operation(s). In other experiences, Revinax® recorded simultaneously the firstperson POV of different members of the surgical team. The ability to switch to other
views allows the learner to envision what other members of the surgical team are
doing at specific points within the surgery.
As described in Ros et al. (2017), when surveyed, a large majority of participants
viewing the immersive VR environment tutorial saw the benefit of using it as a
part of the teaching program and felt that it had a beneficial effect on their learning
outcomes. One of the interesting results obtained from this study was that there
were no age differences observed (i.e., cohort was composed of a wide range of
healthcare professionals from young students to old practitioners). Indeed, as this
is a video-based environment, people may be familiar with the context. This helps
to bridge and reduce/attempt to eliminate the technical gap, which can be perceived
across real/VR environment and the academic achievement gap observed by students
based on their learning styles (Neuwirth, Ebrahimi, Mukherji & Park, 2018; 2019)
109

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

and how redefining student diversity may further influence these outcomes across
generations (Mukherji, Neuwirth & Limonic, 2017). Other studies have been
launched, including more than 450 participants attempting to address these very
issues at the core of modern learning and immersive VR environment integration
as a powerful pedagogical tool. The first set of results have helped increase how
to understand the place and/or setting in which using immersive VR environment
would be most optimal for the learner within this environment. One way this was
achieved was to assess the retrieval, reconsolidation, and retention of knowledge
by comparing a group that read a technical note versus another group that had been
exposed to the same technical note plus access to the immersive VR environment.
Students who were trained with the immersive VR environment showed significantly
better immediate memorization than students trained without the immersive VR
environment. The same trend was observed (i.e., without reaching significance)
in the groups six months post-training. Another study aimed to assess hands-on
training within immersive VR environment compared to another group who had a
traditional lecture. The results showed that the immersive VR environment helped
to speed up the time to complete the procedure. Interestingly, both groups had the
same results while checking the items corresponding to the different steps of the
procedure. This controlled for the key differences the users experience through the
immersive VR environment. The outcomes showed that the lecture group performed
better in answering theory-based questions prior to completing the procedure. One
of the values of developing immersive VR environment tutorials are: the tutorial
is affordable, easy to comprehend, and facilitates efficient learning; these benefits
can help address the problems reported by the World Health Organization (WHO)
(2015) concerning surgical training globally. Indeed, not everyone can afford to have
access to a laboratory or an operating room with the highest caliber of technology,
but a simulation training center may help to leverage the financial and practical
problems surgeons face globally by expanding telemedicine through such applied
VR pedagogical applications.

Challenges of Immersive VR Environments and
How the Revinax® Model Addresses Them
Some VR hardware requires the trainer or educator to have specialized knowledge
(Concannon et al., 2019), which can be a barrier to deploying the “full” VR experience.
Some VR environments lack visual realism due to the limits of producing accurate
graphics, while inaccurate or unrealistic details can further deviate away from the
intended immersive VR experience; thereby, detracting the user from the believability
of the immersive VR experience (Kamińska et al., 2019). As such, creating a more
realistic environment can increase the cost of producing the VR experience or lead to
110

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

other restrictions such as limiting the interactivity of the VR experience (Kamińska
et al., 2019). One of the reasons that Revinax® chose to use the 180-degree videobased immersive VR environment first-person POV experience was that trainers did
not require much specialized knowledge to use the technology. Further, it also allows
the user to create content that is intrinsically realistic and more familiar to the user.
Thus, the users can adapt to the content easily, which may help to integrate it in a
wide-range of educational training programs. Further, video-based immersive VR
environments helps to decrease the price to create content, and is able to represent
a wide range of situations as pedagogical context for instructional use. Although,
there are various ways to create video, the first-person POV has been proven to be an
important pedagogical tool with more efficiency over other video content. Finally,
Revinax® has committed to make content available through easy deployment and
provide users the choice of a cross-platform approach in order to deliver the content
in a VR standalone headset along with smartphones.

INCORPORATING VR INTO A TRAINING PROGRAM
Changing an already existing training program or creating a new training program
should always begin with a user needs assessment. During this assessment phase,
multiple options for training delivery should be assessed and the decision to use
immersive VR environments as part of the training program along with the justification
should be documented. Although Concannon, Esmail & Roduta Roberts (2019) found
a positive outcome for immersive VR environments in 35 out of 38 experiments
they reviewed (i.e., 92% efficacy rate), caution should be exercised as immersive
VR environments is not the solution for every training problem nor should it be
used just because it is an attractive technology. Regarding the theoretical knowledge,
immersive VR environments can be used as mentioned for a conceptual/structural
understanding. Likewise, the procedural and practical knowledge for immersive
VR environments should be considered when the training problem that needs to be
addressed is related to experiential training. Experiential Training corresponds to
the fact the learner needs to live the situation, to understand, gain experiences and
thus will be able to become proficient. How to define when experiential training is
indicated? When it is only the fact to have lived the experiences, which allows the
trainee to have a full understanding. When you wonder how to show people and
you are thinking the best way would be to take everyone in that context to make
them live the experience, experiential training is indicated. Although technology
and learning pedagogies have developed considerably over the last 15 years, the
approach that Ruiz, Mintzer & Leipzig (2006) provided helps the field to better
understand the pedagogical value of incorporating different learning methods into
111

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

immersive VR environments. “Traditional instructor-centered teaching is yielding to
a learner- centered model that puts learners in control of their own learning” (Ruiz
et al., 2006, p. 207). Specifically, experiential learning and social constructivist
learning theory accompanies the incorporation of immersive VR environments
into any training program (Concannon et al., 2019). Adults learn better, when they
are able to determine what they need to learn, explore the topics themselves, and
then apply their knowledge actively. The autonomous and experiential nature of
virtual reality makes it a good-fit with adult learning theory. Consistent with this
approach, this is why Revinax® wanted to create a learner-centered experience in
which the user feels being directly immersed within the middle of any immersive
VR learning environment to have access to everything he or she needs surrounding
them to enhance their learning.
Once it is determined that virtual reality should be used, it is important to define
which kind of “VR” would be the best pedagogical and instructional method to
answer the users’ training objectives: Through CGI – when the context cannot be
represented for practical or for conceptual knowledge / 360-degree based-video
display to understand a given context, can be considered procedural. In contrast,
the 180-degree first-person POV for teaching practical or procedural content with
the goal to be deployed at large scale. Of course, the cost of the content creation,
its volume, the hardware used to deploy it, and the number of people who have to
undergo the experience can increase the variability of the outcomes and the potential
applied cross-applications of any given pedagogical VR intervention.. However,
Górski et al. (2017) identified a sound methodology for building Knowledge-Oriented
Medical Virtual Reality (KOMVR), which is a six-step process: 1) identification, 2)
justification, 3) knowledge acquisition, 4) knowledge formalization, 5) application
and 6) implementation. From such a pedagogical needs assessment, the educator
can define the user group and what they want the learner to accomplish during the
training. As such, the theoretical framework for the KOMVR maps directly onto
the training objectives to facilitate a deeper level of knowledge and from there to
produce a range of acquired skills that may be useful for theoretical, practical,
procedural, yet generalizable behaviors with the intent for applied purposes, within
the immersive VR environment and potentially the real-world.
The second stage of KOMVR is justification, which includes planning who
should be a part of the development team, estimating the work hours, calculating
hardware and software costs, obtaining funding or developing a business plan and
assessing the project risks (Górski et al., 2017). During the development process,
the immersive VR environmental experiences should be tested by a diverse group of
potential users/stakeholders to obtain feedback relating to functionality, effectiveness
and the capability that addresses whether or not the experience adds to the training
program (Kamińska et al., 2019). This can be done with a combination of survey
112

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

questions targeting usability such as the System Usability Scale (Kamińska et al.,
2019) and open questions to determine simple improvements that could enhance
learning and the user experience. It is important to obtain feedback from a range
of users as well as teachers and surgical experts in the field as the system and the
experience will be viewed very differently by these groups.

CONCLUSION
The motivation and impetus to develop the immersive VR environment tutorial was
brought on by the experiences users reported from the training program. Due to
the practical limitations of shadowing surgeons within crowded operating rooms,
the inherent set backs were the difficulty of medical professionals being allowed
an appropriate/optimal view it of the surgical and nursing procedures that would
increase their pedagogical applications of what they learned via direct observation
of every procedure. The surgeon “mentoring” via shadowing within the operating
room happens with the trainees /medical professional assisting the mentor. Since the
trainee/medical professional is usually shadowing beside, behind, or even facing the
surgeon the learning/pedagogical vantage point/perspective may be a self-limiting
variable within the pedagogical approaches in acquiring skill acquisition of the surgical
technique under study. Even when the user can see accurately what on the surgeon
is doing via shadowing in real-time, they may not have the correct vantage point in
order to acquire, consolidate, reconsolidate, and generalize the correct translational
application of the surgical technique under study through natural observation means.
Thus, the human brain has arguably some learning limitations through which it
can optimally acquire information in which it may not fully/correctly memorize
information in which it is presented. Further, the human brain can inadvertently
make mistakes during the learning acquisition period, when the individual is tasked
with attempting to (re)produce the surgical procedure from conceptual to practical
generalizations. This is one explanation as to why it increases learning competency
to acquire the skill acquisition procedures to reproduce these practical skills.
Moreover, the observer through this shadowing/naturalistic observation methods
may have learned something through the process, but due to the constraints of the
human attention span and environmental distractors, how much is accurately learned
in order to generalize and apply to practical application may be more limited than
once thought. Thus, it poses the question, how can one address this inherent learning
gap when trying to acquire new information during real-time surgical shadowing/
observation (i.e., which is what is conventionally considered the status quo)?

113

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

Additionally, through this comprehensive, yet conceptualize understanding of the
limitations of shadowing and naturalistic observations, the present study proposes
that it was not possible to provide/optimize these experiences to surgeons locally
or abroad in other countries. A Lancet report (2015) for WHO stated that surgery
should be considered as one of the top priority medical interventions for advancing
global health. The catalyst for this is that five billion people globally do not have
access to surgery. Further, to maintain this insufficient medical coverage, the surgical
workforce (i.e., not only surgeons, but inclusive of all medical health professionals
participating in surgeries) needs to double by 2030 to address this very issue.
Teaching people essential surgeries (across ~44 medical procedures) could save up
to five millions lives per year. The theory behind this proposes the question, how
then can we achieve that goal? The answer may lie at the interface of training people
in remote areas with telemedicine through immersive VR environments from more
advanced medical areas globally? From these immersive VR experiences, a global
telemedicine workforce may be assembled to address these very issues. Further,
to provide surgeons/surgical students and medical professionals with a portable/
accessible tool, which can help them to have a better conceptual and translational
understanding of a surgical procedure through immersive VR, may help to circumvent
the pedagogical inherent issues in natural shadowing/observations through a more
immersive VR environment as with the Revinax® model that addresses these issues
to optimize the pedagogical outcomes of the surgeon/medical professional to increase
future generations of biomedical educators in the field.

REFERENCES
Aggarwal, R., Ward, J., Balasundaram, I., Sains, P., Athanasiou, T., & Darzi, A. (2007).
Proving the effectiveness of virtual reality simulation for training in laparoscopic
surgery. Annals of Surgery, 246(5), 771–779. doi:10.1097/SLA.0b013e3180f61b09
PMID:17968168
Aïm, F., Lonjon, G., Hannouche, D., & Nizard, R. (2016). Effectiveness of virtual
reality training in orthopaedic surgery. Arthroscopy, 32(1), 224–232. doi:10.1016/j.
arthro.2015.07.023 PMID:26412672
Alaker, M., Wynn, G. R., & Arulampalam, T. (2016). Virtual reality training in
laparoscopic surgery: A systematic review & meta-analysis. International Journal
of Surgery, 29, 85–94. doi:10.1016/j.ijsu.2016.03.034 PMID:26992652

114

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

Andersen, C., Winding, T. N., & Vesterby, M. S. (2010). Development of simulated
arthroscopic skills. Journal Acta Orthopaedica, 82(1), 90–95. doi:10.3109/174536
74.2011.552776 PMID:21281257
Andersen, S. A. W., Foghsgaard, S., Cayé-Thomasen, P., & Sørensen, M. S.
(2018). The effect of a distributed virtual reality simulation training program on
dissection mastoidectomy performance. Otology & Neurotology, 39(10), 1277–1284.
doi:10.1097/MAO.0000000000002031 PMID:30303946
Anderson, S. A. W., Mikkelsen, P. T., Konge, L., Cayé-Thomasen, P., & Sørensen, M.
S. (2016). Cognitive load in mastoidectomy skills training: Virtual reality simulation
and traditional dissection compared. Journal of Surgical Education, 73(1), 45–50.
doi:10.1016/j.jsurg.2015.09.010 PMID:26481267
Bandura, A., Ross, D., & Ross, S. A. (1963). Vicarious reinforcement and immitative
learning. Journal of Abnormal and Social Psychology, 67(6), 601–607. doi:10.1037/
h0045550 PMID:14084769
Barrouillet, P., Bernardin, S., Portrat, S., Vergauwe, E., & Camos, V. (2007). Time
and cognitive load in working memory. Journal of Experimental Psychology.
Learning, Memory, and Cognition, 33(3), 570–585. doi:10.1037/0278-7393.33.3.570
PMID:17470006
Cates, C. U., Lönn, L., & Gallagher, A. G. (2016). Prospective, randomised and
blinded comparison of proficiency-based progression full-physics virtual reality
simulator training versus invasive vascular experience for learning carotid artery
angiography by very experienced operators. BMJ Simulation and Technology
Enhanced Learning, 2(1), 1–5. doi:10.1136/bmjstel-2015-000090
Chao, C. J., Wu, S. Y., Yau, Y. J., Feng, W. Y., & Tseng, F. Y. (2017). Effects of
three-dimensional virtual reality and traditional training methods on mental workload
and training performance. Human Factors and Ergonomics in Manufacturing, 27(4),
187–196. doi:10.1002/hfm.20702
Concannon, B. J., Esmail, S., & Roduta Roberts, M. (2019). Head-Mounted Display
Virtual Reality in Post-secondary Education and Skill Training. Frontiers in Education,
4(August), 1–23. doi:10.3389/feduc.2019.00080
Ekstrand, C., Jamal, A., Nguyen, R., Kudryk, A., Mann, J., & Mendez, I. (2018).
Immersive and interactive virtual reality to improve learning and retention of
neuroanatomy in medical students: A randomized controlled study. CMAJ Open,
6(1), E103–E109. doi:10.9778/cmajo.20170110 PMID:29510979

115

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

Feldon, D. F. (2007). Cognitive load and classroom teaching: The doubleedged sword of automaticity. Educational Psychologist, 42(3), 123–137.
doi:10.1080/00461520701416173
Fiorella, L., Van Gog, T., Hoogerheide, V., & Mayer, R. E. (2017). It’s all a matter of
perspective: Viewing first-person video modeling examples promotes learning of an
assembly task. Journal of Educational Psychology, 109(5), 653–665. doi:10.1037/
edu0000161
Fowler, C. (2015). Virtual reality and learning: Where is the pedagogy? British
Journal of Educational Technology, 46(2), 412–422. doi:10.1111/bjet.12135
Górski, F., Bun, P., Wichniarek, R., Zawadzki, P., & Hamrol, A. (2017). Effective
design of educational virtual reality applications for medicine using knowledgeengineering techniques. Eurasia Journal of Mathematics. Science and Technology
Education, 13(2), 395–416. doi:10.12973/eurasia.2017.00623a
Gurusamy, K., Aggarwal, R., Palanivelu, L., & Davidson, B. R. (2008). Systematic
review of randomized controlled trials on the effectiveness of virtual reality training
for laproscopic surgery. British Journal of Surgery, 95(9), 1088–1097. doi:10.1002/
bjs.6344 PMID:18690637
Haque, S., & Srinivasan, S. (2006). A meta-analysis of the training effectiveness of
virtual reality surgical simulators. IEEE Transactions on Information Technology
in Biomedicine, 10(1), 51–58. doi:10.1109/TITB.2005.855529 PMID:16445249
Iacoboni, M. (2009). Immitation, empathy, and mirror neurons. Annual Review
of Psychology, 60(1), 653–670. doi:10.1146/annurev.psych.60.110707.163604
PMID:18793090
Izard, S. G., Juanes, J. A., García Peñalvo, F. J., Estella, J. M. G., Ledesma, M.
J. S., & Ruisoto, P. (2018). Virtual reality as an educational and training tool for
medicine. Journal of Medical Systems, 42(3), 1–5. doi:10.100710916-018-0900-2
PMID:29392522
Jensen, L., & Konradsen, F. (2018). A review of the use of virtual reality headmounted displays in education and training. Education and Information Technologies,
23(4), 1515–1529. doi:10.100710639-017-9676-0
Kamińska, D., Sapiński, T., Wiak, S., Tikk, T., Haamer, R. E., Avots, E., ... Anbarjafari,
G. (2019). Virtual reality and its applications in education: Survey. Information
(Switzerland), 10(10), 1–20. doi:10.3390/info10100318

116

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

Mandal, S. (2013). Brief introduction of virtual reality & its challenges. International
Journal of Scientific & Engineering Research, 4(4), 304–309.
Maresky, H. S., Oikonomou, A., & Ali, I. (2018). Virtual reality and cardiac
anatomy: Exploring immersive three-dimensional cardiac imaging, a pilot study in
undergraduate medical anatomy education. Clin Anat N Y N. doi:10.1002/ca.23292
Meara, J. G., Leather, A. J. M., Hagander, L., Alkire, B. C., Alonso, N., Ameh, E.
A., Bickler, S. W., Conteh, L., Dare, A. J., Davies, J., Mérisier, E. D., El-Halabi, S.,
Farmer, P. E., Gawande, A., Gillies, R., Greenberg, S. L. M., Grimes, C. E., Gruen, R.
L., Ismail, E. A., ... Yip, W. (2015). Global Surgery 2030: Evidence and solutions for
achieving health, welfare, and economic development. Lancet, 386(9993), 569–624.
doi:10.1016/S0140-6736(15)60160-X PMID:25924834
Mock, C. N., Donkor, P., Gawande, A., Jamison, D. T., Kruk, M. E., & Debas, H.
T. (2018). Essential surgery: Key messages from Disease Control Priorities. Lancet,
391(10125), e11–e14. doi:10.1016/S0140-6736(15)60091-5 PMID:25662416
Mukherji, B.R., Neuwirth, L.S., & Limonic. (2017, Apr.). Making the case for real
diversity: Redefining underrepresented minority students in public universities.
Sage Open, 1-10.
Neuwirth, L. S., Dacius, T. F. Jr, & Mukherji, B. R. (2018). Teaching neuroanatomy
through a historical context. Journal of Undergraduate Neuroscience Education,
16(2), E26–E31. PMID:30057504
Neuwirth, L. S., Ebrahimi, A., Mukherji, B. R., & Park, L. (2018). Addressing
diverse college students and interdisciplinary learning experiences through online
virtual laboratory instruction: A theoretical approach to error-based learning in
biopsychology. In A. Ursyn (Ed.), Visual approaches to cognitive education with
technology integration (pp. 283–303). IGI. doi:10.4018/978-1-5225-5332-8.ch012
Neuwirth, L. S., Ebrahimi, A., Mukherji, B. R., & Park, L. (2019). Addressing
diverse college students and interdisciplinary learning experiences through online
virtual laboratory instruction: A theoretical approach to error-based learning in
biopsychology. Hershey, PA: IGI. doi:10.4018/978-1-5225-8179-6.ch025
Oviatt, S. (2006). Human-centered design meets cognitive load theory: Designing
interfaces that help people think. Proceedings of the 14th AMC International
Conference on Multimedia, 871-880.

117

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

Ragan, E.D., Bowman, D.A., Kopper, R., Stinson, C., Scerbo, S. & McMahan, R.P.
(2015). Effects of field of view and visual complexity on virtual reality training
effectiveness for a visual scanning task. IEEE Transactions on Visualization and
Computer Graphics, 21(7), 794-807.
Ros, M., & Neuwirth, L. S. (2020). Increasing global awareness of timely COVID-19
healthcare guidelines through FPV training tutorials: Portable public health
crises teaching method. Nurse Education Today, 91(104479), 1–6. doi:10.1016/j.
nedt.2020.104479
Ros, M., Trives, J. V., & Lonjon, N. (2017). From stereoscopic recording to virtual
reality headsets: Designing a new way to learn surgery. Neuro-Chirurgie, 63(1),
1–5. doi:10.1016/j.neuchi.2016.08.004 PMID:28233530
Roussou, M. (2000). Immersive interactive virtual reality and informal education.
Proceedings of i3 Workshop on Interactive Learning Environments for Children, 1-9.
Ruiz, J. G., Mintzer, M. J., & Leipzig, R. M. (2006). The impact of e-learning in
medical education. Academic Medicine, 81(3), 207–212. doi:10.1097/00001888200603000-00002 PMID:16501260
Sheik-Ali, S., Edgcombe, H., & Paton, C. (2019). Next-generation Virtual and
Augmented Reality in Surgical Education: A Narrative Review. Surgical Technology
International, 35, 27–35. PMID:31498872
Smith, S. J., Farra, S. L., Ulrich, D. L., Hodgson, E., Nicely, S., & Mickle, A.
(2018). Effectiveness of Two Varying Levels of Virtual Reality Simulation. Nursing
Education Perspectives, 39(6), E10–E15. doi:10.1097/01.NEP.0000000000000369
PMID:30335708
Sturm, L. P., Windsor, J. A., Cosman, P. H., Cregan, P., Hewett, P. J., & Maddern, G. J.
(2008). A systematic review of skills transfer after surgical simulation training. Annals
of Surgery, 248(2), 166–179. doi:10.1097/SLA.0b013e318176bf24 PMID:18650625
Sutherland, J., Belec, J., Sheikh, A., Chepelev, L., Althobaity, W., Chow, B. J. W.,
Mitsouras, D., Christensen, A., Rybicki, F. J., & La Russa, D. J. (2019). Applying
modern virtual and augmented reality technologies to medical images and
models. Journal of Digital Imaging, 32(1), 38–53. doi:10.100710278-018-0122-7
PMID:30215180

118

Virtual Reality Stereoscopic 180-Degree Video-Based Immersive Environments

Van Gog, T., Paas, F., Marcus, N., Ayres, P., & Sweller, J. (2009). The mirror neuron
system and observational learning: Implications for the effectiveness of dynamic
visualizations. Educational Psychology Review, 21(1), 21–30. doi:10.100710648008-9094-3
Vankipuram, A., Khanal, P., Ashby, A., Vankipuram, M., Gupta, A., DrummGurnee,
D., Josey, K., & Smith, M. (2014). Design and development of a virtual reality simulator
for advanced cardiac life support training. IEEE Journal of Biomedical and Health
Informatics, 18(4), 1478–1484. doi:10.1109/JBHI.2013.2285102 PMID:24122608
Vaughan, N., Dubey, V. N., Wainwright, T. W., & Middleton, R. G. (2016). A review of
virtual reality based training simulators for orthopaedic surgery. Medical Engineering
& Physics, 38(2), 59–71. doi:10.1016/j.medengphy.2015.11.021 PMID:26751581

119